Stanton County Health Care: Pulse Never Checked - KS
The woman, identified in inspection records only as R11, has dementia and requires substantial help with daily tasks including bathing. She takes digoxin, a drug used to treat atrial fibrillation and heart rhythm problems, and carvedilol, a beta-blocker. Both medications require vital sign monitoring before administration — digoxin requires a pulse check, carvedilol a blood pressure reading — because dangerous drops or irregularities can signal that a dose should be withheld.
Staff skipped the pulse check before every digoxin dose in May, June, July, and August of 2025. That is 31 missed checks in May, 30 in June, 31 in July, and 27 in August, for a total of 119 opportunities across four months. In May alone, staff also failed to check R11's blood pressure before giving her carvedilol on all 31 days of the month.
The facility's own care plan, last revised in April, directed staff only to give medications as directed. It contained no specific guidance on digoxin or carvedilol at all.
A consultant pharmacist conducted monthly medication reviews and attended monthly pharmacy and therapeutics meetings alongside the facility's physician, according to Administrative Nurse D, who spoke with inspectors on August 26. The pharmacist's reviews, however, contained no recommendation that staff monitor R11's pulse before administering digoxin.
Nobody caught it. Not the nurses giving the medication. Not the pharmacist reviewing it each month. Not the physician attending those meetings.
R11's digoxin order was also rewritten in May 2025 in a way that changed the dosage instructions, moving from a straightforward daily order to a formulation specifying a tablet strength and a separate daily amount. Whether staff administered the correct dose under the new order, inspectors did not document.
R11 has dementia. She cannot advocate for herself when a nurse skips a step.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stanton County Health Care Facility Ltcu from 2025-08-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
STANTON COUNTY HEALTH CARE FACILITY LTCU in JOHNSON, KS was cited for violations during a health inspection on August 28, 2025.
The woman, identified in inspection records only as R11, has dementia and requires substantial help with daily tasks including bathing.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.